Complaint Form For An Order Of Protection From Domestic Violence Page 3
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4STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
FAMILY COURT
For these reasons, I respectfully request that the Family Court ORDER: (Check and
complete any that apply.)
That ___________________________________________________________________
be restrained and enjoined from contacting, assaulting, molesting, stalking, cyberstalking,
cyberbullying, bullying, harassing, threatening,
annoying, or otherwise interfering with me
and/or ____________________________________________________________ at home, at
school, on the street, or elsewhere.
That ___________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
I request that relief be ordered without notice because of the specific facts set forth in this
Complaint and the attached affidavit. I and/or the children will suffer immediate and irreparable
injury, loss, or damage before notice can be served on the Defendant(s) and a hearing can be held
on this Complaint.
The Family Court will schedule a hearing no later than twenty-one (21) days after the Ex
Parte Temporary Order of Protection from Domestic Violence, if any, is entered. At the hearing
I will present evidence in support of my Complaint.
I understand that if I fail to appear at the scheduled hearing date, the Ex Parte
Temporary Order of Protection from Domestic Abuse and this Complaint will be
dismissed.
Name of the Plaintiff
_____________________________________________________________________
Signature of the Plaintiff
_____________________________________________________________________
Address:
Telephone Number:
Date:
FC-53 (revised October 2014)
Page 3 of 4
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